PCLS Spousal Verification Form 2027

Secure Spousal Verification

PAINESVILLE CITY LOCAL SCHOOLS
For spousal verification, other medical coverage includes employer-sponsored coverage, retiree coverage, and government-sponsored coverage.

Do not proceed until you have each of the required documents listed above. Incomplete submissions will not be accepted. To ensure the security of your personal information, all documents must be submitted via this encrypted form. Only the questions and uploads displayed for your answers are required; additional comments are optional.

Section 1 - Employee & Spouse Information
Employee Name

First NameLast Name
Employee Work Email
example@example.com
Employee Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Name

First NameLast Name
Have you received a Case Reference?
Case Reference

Section 2 - Required Documentation
Does your spouse currently have access to other medical coverage?
Other Medical Coverage Details
You can keep your spouse on the PCLS medical plan; however, you will be subject to a $200 per month surcharge in addition to the standard monthly premiums. If you wish to drop your spouse from coverage to avoid the surcharge, please contact HR.
Is Your Spouse Currently Employed or Self-Employed?
Upload the completed Working Spouse Attestation

Required only if your spouse is employed or self-employed. Download at https://www.mypclsbenefits.com/wsa.
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Did you and your spouse file your 2025 Federal Tax Return as "Married Filing Jointly"?
Did your spouse file a separate 2025 Federal Tax Return?
Upload page 1 of your most recent Form 1040, showing your name, your spouse's name, and Line 1a.

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Upload page 1 of your spouse's 2025 Form 1040, showing their name and Line 1a.

Be sure to black-out any Social Security Numbers before sending.
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Upload the spouse's 2025 IRS Verification of Non-Filing Letter.

Be sure to black-out any Social Security Numbers before sending.
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Upload Proof of Joint Financial Responsibility.

Show both names and the document date. Documents must be dated within the last 60 days, except jointly filed federal or state tax returns may be from the applicable tax filing period. Redact SSNs, account numbers and unrelated details.
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For validation, enter the amount shown on Line 1a of the Form 1040 you uploaded above.

Additional Information and Attestation
OPTIONAL: Is there any additional information you would like to share regarding the verification or documents you provided (i.e., spouse recently lost coverage) to assist in the verification? Your response will be documented with the verification details.
I certify this information is true, correct, and current. I understand false, incomplete, or misleading information may result in the surcharge, corrected premiums or benefits, recovery of amounts owed, and other penalties. I authorize verification of these facts with appropriate organizations for that limited purpose.
Should be Empty:

Secure Spousal Verification

Section 1 - Employee & Spouse Information

Section 2 - Required Documentation

Additional Information and Attestation